Do we need to hold Eliquis (apixaban) for atrial fibrillation prior to cortisone shots?

Management of Eliquis (Apixaban) for Cortisone Injections in Atrial Fibrillation Patients

Eliquis (apixaban) does not need to be held prior to cortisone injections in patients with atrial fibrillation, as cortisone injections are considered a low bleeding risk procedure. 1

Understanding Bleeding Risk Categories for Procedures

• Cortisone injections fall into the category of procedures with low bleeding risk, where the bleeding would be non-critical in location and easily controlled 1
• For procedures with low bleeding risk, the FDA label for apixaban specifically states that it should be discontinued at least 24 hours prior to the procedure 1
• However, for minor procedures with minimal bleeding risk (such as joint injections), anticoagulation does not have to be modified 2

Official Recommendations for Perioperative Management

• For procedures with only a minor risk of bleeding, NOACs (including apixaban) do not have to be interrupted 2
• The 2019 AHA/ACC/HRS guidelines focus on cardioversion procedures requiring anticoagulation but do not recommend interruption for minor procedures 2
• The 2024 ESC guidelines similarly do not recommend interruption of anticoagulation for minor procedures with minimal bleeding risk 2

Risk Assessment and Decision-Making

• The decision to continue or interrupt anticoagulation should be based on:

  • The bleeding risk of the procedure (cortisone injections have low bleeding risk) 1
  • The patient's thromboembolic risk profile (CHA₂DS₂-VASc score) 2
  • The bleeding risk profile of the patient 2

• For patients with high thromboembolic risk, maintaining anticoagulation is particularly important to prevent stroke 2

Specific Guidance for Eliquis (Apixaban)

• According to the FDA label, apixaban should be discontinued at least 24 hours prior to procedures with a low risk of bleeding 1
• However, for minimal risk procedures like cortisone injections, clinical guidelines suggest that interruption is not necessary 2
• If interruption is deemed necessary based on individual factors, apixaban can be restarted as soon as adequate hemostasis has been established 1

Important Considerations

• Bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required 1
• The risk of thromboembolism increases significantly when anticoagulation is interrupted, especially in patients with high CHA₂DS₂-VASc scores 2
• Unnecessary interruption of anticoagulation may expose patients to increased risk of stroke or systemic embolism 2

Common Pitfalls to Avoid

• Unnecessarily interrupting anticoagulation for low-risk procedures, which can increase thromboembolic risk 2
• Failing to restart anticoagulation promptly after the procedure if it was interrupted 1
• Not considering the patient's individual thromboembolic and bleeding risk profiles when making decisions about perioperative anticoagulation management 2

In conclusion, for most patients on Eliquis (apixaban) for atrial fibrillation who are undergoing cortisone injections, the anticoagulant can be safely continued without interruption due to the low bleeding risk associated with the procedure.